| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,745 |
1,720 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
634 |
389 |
$83K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
333 |
236 |
$58K |
| D1206 |
Topical application of fluoride varnish |
1,792 |
1,772 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,522 |
1,506 |
$36K |
| D0274 |
Bitewings - four radiographic images |
982 |
967 |
$33K |
| D0330 |
Panoramic radiographic image |
631 |
609 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
788 |
761 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
371 |
356 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
698 |
658 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
24 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
200 |
$7K |
| D2740 |
Crown - porcelain/ceramic |
12 |
12 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
55 |
$6K |
| D4910 |
|
95 |
95 |
$6K |
| D2950 |
|
38 |
37 |
$5K |
| D3120 |
|
15 |
12 |
$470.48 |
| D0603 |
|
12 |
12 |
$121.77 |
| D1999 |
|
173 |
135 |
$51.00 |